Woodard LD (HCQCUS, Baylor College of Medicine), Urech T
(HCQCUS), Robinson C
(HCQCUS), Kuebeler M
(HCQCUS), Campbell Hasche J
(HCQCUS), Pietz K
(HCQCUS), Sookanan Chitwood S
(HCQCUS), Daw C
(HCQCUS), Petersen LA
(HCQCUS, Baylor College of Medicine)
Avoiding inappropriate treatment of chronically ill patients with limited life expectancy (LLE) is an important consideration for pay-for-performance and quality improvement programs. We examined treatment intensification for patients with diabetes and LLE.
We identified patients with diabetes utilizing VA health care in FY 2007 using diagnosis codes, glucose readings, or prescription of diabetes medications in VA administrative data sources. We then identified a subset of diabetic patients that met at least one LLE indicator. We defined condition-specific algorithms to identify seriously ill patients with any of the following: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), dementia, end-stage liver disease (ESLD), and primary/metastatic cancers. We compared diabetes quality of care for glycemic and lipid control at index [Hemoglobin (Hb) A1c < 7%, low-density lipoprotein (LDL) < 100 mg/dL], treatment intensification for uncontrolled readings within eight weeks, and overall quality (control at index + treatment intensification) among diabetic patients with and without LLE. We excluded facilities that did not have complete laboratory data.
44,555 (5.1%) diabetic patients had at least one LLE indicator, ranging from 3.9% to 6.4% across VA networks. Compared to diabetic patients without LLE , those identified as having LLE were more likely to have HbA1c and LDL levels controlled at index (50.6% vs. 46.2%; p < 0.001; 54.8% vs. 51.2%; p < 0.001) and receive appropriate overall quality (66.1% vs. 65.4%; p = 0.003; 67.6% vs. 66.6%, p = 0.001). LLE patients were less likely to receive treatment intensification in response to elevated HbA1c or LDL levels (31.3% vs. 35.6%; p < 0.001; 28.2% vs. 31.6%; p < 0.001).
Contrary to our hypothesis, LLE patients were more likely than those without LLE to have HbA1c and LDL levels controlled at index and to receive appropriate diabetes care overall. However, they were less likely to receive treatment intensification for elevated levels, which likely reflects appropriate care in the setting of a life-limiting condition.
Providers appear to be appropriately less aggressive in treating patients with LLE. Further research is needed to determine if these findings persist across other measures of chronic illness care.